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Wisconsin State Laboratory of Hygiene Case Study Youngmi Kim, MS, ASCP(M) Senior Microbiologist, Wisconsin State Laboratory of Hygiene WISCONSIN STATE LABORATORY OF HYGIENE 2 31 year old female from Kenosha County • Strong TB suspect: foreign born, abnormal CXR, positive QFT • Received sputa for smear and culture collected 2/20, 2/21, and 2/22/13 WISCONSIN STATE LABORATORY OF HYGIENE 3 • Two of the three specimens were smear positive (1+ and 3+), but TB PCR was negative for both • Specimen sent to CA PHL for parallel testing (WI & CA Shared Services Project) – NAAT – MDDR (CA only) – Conventional TB DST WISCONSIN STATE LABORATORY OF HYGIENE 4 • CA lab had a weak positive NAAT result and contacted WI SLH for more information on the patient. • California was hesitant to send out a positive result, given WSLH’s TB PCR results (both negative). • CA report 3/1/13: “identification of MTB is inconclusive”. WISCONSIN STATE LABORATORY OF HYGIENE 5 MGIT became positive (GU=2278) 3/4/13 WISCONSIN STATE LABORATORY OF HYGIENE 6 WISCONSIN STATE LABORATORY OF HYGIENE 7 • HPLC :Prelim reported as MAIS 3/6/13 • Positive MGIT growth subcultured to »7H10, LJ, & 7H9 WISCONSIN STATE LABORATORY OF HYGIENE 8 3/12/13: Small colonies with cording in 1st quadrant noticed amongst the confluent MAC growth WISCONSIN STATE LABORATORY OF HYGIENE 9 3rd Quadrant of 7H10 plate WISCONSIN STATE LABORATORY OF HYGIENE 10 • 3/12/13: TB PCR performed from MGIT broth was positive for M. tbc (Ct=22) • Tried very hard to isolate M. tbc for susceptibility testing – Growth in broth containing clarithromycin – Growth on plate with clarithromycin disk WISCONSIN STATE LABORATORY OF HYGIENE 11 • 4/15/13 at WSLH: M. tbc isolated & 1st line DST set up (49 days after receipt) • CA PHL report 3/18/13: – MDDR testing: no mutations that confer resistance to INH, rifampin, quinolones or injectables WISCONSIN STATE LABORATORY OF HYGIENE 12 • 4/25/13 – 1st line DST result out as pan susceptible to all 4 drugs WISCONSIN STATE LABORATORY OF HYGIENE 13 Specime n # (All Sputum) DOC Smear Culture 13MM1811 2/20/13 Neg MAC & M. tbc 13MM1835 2/21/13 1-9/ f MAC & M. tbc 13MM1864 2/22/13 1-9/100 f MAC 13MM2189 3/15/13 Neg MAC 13MM2580 4/9/13 1-9/100 f MAC 13MM2579 4/10/13 Questionable MAC 13MM2606 4/11/13 Neg MAC 13MM2712 4/17/13 Neg MAC 13MM2809 4/23/13 1-9/100 f MAC 13MM2940 4/30/13 Neg MAC 13MM3003 5/6/13 Neg MAC 13MM3152 5/10/13 Neg MAC WISCONSIN STATE LABORATORY OF HYGIENE 14 Questions for County PHN • Any signs and symptoms? WISCONSIN STATE LABORATORY OF HYGIENE 15 Questions for County PHN • Any signs and symptoms? –No WISCONSIN STATE LABORATORY OF HYGIENE 16 Questions for County PHN • Why was sputum collected? WISCONSIN STATE LABORATORY OF HYGIENE 17 Questions for County PHN • Why was sputum collected? – – – – – – Pre-employment screening at a nursing home Patient refused skin test due to BCG vacc. CXR Abnormal QTF + 3 Sputa collected 2 of 3 Smear Positive WISCONSIN STATE LABORATORY OF HYGIENE 18 TB Risk Factors -came from Cameroon 2 yrs ago -Husband with 2 sons (also pregnant) Husband: CXR Neg, QFT Neg 5 yr old: CXR a little abnormal QFT Pos 1.5 yr old: CXR Neg, QFT Neg WISCONSIN STATE LABORATORY OF HYGIENE 19 Patient Status • Positive culture for M. tbc on 3/13/13 • Patient pulled out of employment and placed in respiratory isolation • Contact investigation: 80 residents and 100 staff members skin tested; all negative • Patient on 3 drug regimen (no PZA) – Till end of Dec. 2013 / DOT – Refused 5 year old son to be treated – Had a daughter and breast feeding WISCONSIN STATE LABORATORY OF HYGIENE 20